Mr Ireland; on admission to Pinderfields General Hospital on 11th February 2012 was prescribed Thromboprophylaxis medication in the form 0f Clexane 40 mg which he received on 11th 12th, 14th, 15"h and 16th February 2012. doses were missed namely 13th and 7th February 2012. Although an Expert opinion is that the two missed doses would not on balance of probability have caused or contributed to his death, consider that action should be taken to prevent omissions of such important medication and that an explanation should be given as to why the doses were omitted. The Orthopaedic Surgeon who carried out Mr Ireland's operation did not consider it inappropriate for him to be given his Clexane on 13th February 2012 i.e. the of surgery: Furthermore, a Junior Doctor did not complete a documented risk assessment for venous thromboembolism: Although this did not affect the actual prescribing; require the Trust to tighten it's procedure in ensuring that the appropriate risk assessments are correctly and appropriately completed: Regarding Mr Ireland's discharge to the Prison's Healthcare Centre on 17th February 2012 at approximately 5.00 pm. Mr Ireland was given an inadequate discharge summary which did not make clear that he had not received his anti-coagulant medication; Clexane, that Health Care Officers were unaware of this and therefore he did not receive this medication on his return to Prison that day. The discharge summary should have made it absolutely clear as to the treatment plan once discharged.' There was a requirement for physiotherapy, yet no enquiries were made about the availability of physiotherapy during the weekend period, which does not exist at the Prison and therefore alternative arrangements were not considered, from leave drugs Two day day: the invite the Trust to review its discharge procedures generally. Specifically consider that the discharge of patients late on Fridays when healthcare services and facilities over a weekend period are severely limited, both in terms of Prison health care and in the wider community can be risky. Although appreciate that hospital places are often scarce and in demand urge the Trust to consider the merits of avoiding late Friday discharge when enquiries have not been made as to the availability of adequate health care provision over a weekend period. In this instance, Mr Ireland would still have been at high risk of developing a deep vein thrombosis and pulmonary embolism, which in fact he did, which was the cause of his death the following Monday_